Key learning points:
– Awareness of patient groups most at risk of dehydration
– The role of the community nurse in early detection of dehydration
– Increased knowledge of the impact which newly published guidelines may have in the early detection and prevention of dehydration
Ensuring that all patients are adequately hydrated and nourished is a fundamental part of health promotion, care and recovery work for all nurses, whatever the context of care. Hydration is essential for survival and the benefits of good hydration for people to function well are widely known. However, current guidance indicates there is no absolute agreement on what constitutes sufficient hydration. The recommended amount of fluids suggested for adults varies between 1.2l to 3.1l per day.1,2 Older adults are calculated to require at least 1.6l per day according to the Institute of Medicine.3
A best practice toolkit, Water for Health, jointly published by the Royal College of Nursing (RCN) and the National Patient Safety Agency,4 promotes professional awareness of the importance of encouraging patients to drink water to avoid dehydration and its associated risks. Yet it seems inconceivable that professional caring staff working with best practice guidance still fail to ensure patients have enough to drink, when unlimited supplies of fresh and safe water are potentially available. Hydration is a fundamental part of care but it is not always given the priority it deserves – despite its association with direct patient harm.5
In UK primary care there has been almost continual transformation of policy and working practices to meet the evolving health needs of the population. It is well understood that patients wish to be treated at home or as close to home as possible.6,7 There are a number of drivers propelling this agenda to keep people out of hospital including patient preference, patient safety and issues relating to financial constraints. Demographics and disease profiles are also rapidly changing. Unprecedented numbers of potentially vulnerable people are now living with complex physical and mental health conditions. Primary care nurses therefore require almost constant upskilling when working with patients from birth to old age.
A malnutrition universal screening tool (MUST) was recently developed to detect patients living at home who are at risk of malnutrition. However, there is no separate validated tool for the assessment of dehydration, which can often be difficult to assess in any setting.8
The fact that some healthcare professionals have been reported to be neglecting the basic needs of patients has been well publicised through recent inquiries into institutional failure to care, as reported most notably by the Mid Staffordshire Inquiry. Francis9 found that hydration in hospital patients was severely compromised as nurses failed to ensure that drinks were available or accessible. Furthermore, there was no mechanism to ensure that the most vulnerable patients were offered adequate assistance to drink. Yet the focus of many guidelines and literature regarding hydration and nutrition is hospitals. However, the Nursing and Midwifery Council (NMC) is explicit in its expectation that all nurses must ensure effective delivery of fundamental person-centred care. This includes hydration.10
Recently published guidelines in 2015 from NHS England11 acknowledge the problem of poor recognition by healthcare staff of both dehydration and malnutrition – not only in hospitals, but also in community settings. Anticipating problems earlier in home and care facilities, by detecting those at risk of dehydration at an earlier stage, would help to reduce levels of morbidity and mortality associated with this all-too-common problem.11
Dehydration has consequences that particularly affect certain patient groups at different points across the age range. As with any alterations to homeostasis within the body, the healthy body has the ability to compensate, but in those with ill health these mechanisms are often less adequate.12 Dehydration refers to water losses from the body that exceed intake, leaving the individual with an accumulation of sodium, which causes a hyperosmolar state.13
In dehydration, population groups such as those at the extremes of the age range are at greater risk, even when healthy, because of fundamental physiology. This is a significant issue for community nurses since both children and older people are routinely cared for in primary care.
Dehydration of frail and elderly people living alone is a significant public health concern. Primary care nurses have a strong public health focus to their roles and are well placed to promote adequate hydration among such community patients. Older adults have the same water requirements as younger adults; however, physiological changes during ageing affect water balance, placing older adults at greater risk of dehydration.14 They are also more likely to experience a reduction in the sense of thirst and communication difficulties, and they might also need to take medications such as diuretics to manage long-term conditions. Additionally, increasing numbers of people with dementia have a higher risk of dehydration due to physiological changes, so these individuals must also be carefully assessed to avoid dehydration problems.15
People with learning disabilities now live longer lives, often into older age, which can also have a complicating impact on their state of wellbeing. Mean life expectancy for this patient group has increased from below 20 years in the 1930s to well over 60 now.16 This group is also more likely to be living in community settings while facing physiological issues that predispose them to increased risk of dehydration. Dysphagia, for example, is more common in people with learning difficulties, making the physical act of swallowing fluid uncomfortable. This can lead to dehydration and increased risk of aspiration, leading to chest infection.17
Issues around dexterity and the ability to prepare drinks and manage the drinking device are also likely to compound this further. In addition, patients with learning difficulties may have their physical needs misinterpreted by healthcare professionals – the phenomenon of ‘diagnostic overshadowing’.
Diagnostic overshadowing is also a recognised problem for people with mental illness. So behaviours such as lethargy and confusion, which can be causally linked to dehydration, might be mistakenly interpreted by health professionals as signs and symptoms of mental illness – for instance depression or dementia.18
Finally, it should be remembered that children are physiologically different from adults due to their greater surface area compared to body mass, greater water turnover and lesser ability to sweat. This means that their fluid requirements are greater than those of an adult,19 and they have an increased risk of becoming dehydrated. Children younger than three years old are at greatest risk of dehydration as their body weight is 80% water. By the age of three this proportion falls to 65%.20
Dehydration can be both a cause and a consequence of illness. Certain groups, as discussed previously, are more susceptible – especially older people and children. Community nurses must be mindful when caring for such patients but also be alert to others who may be at risk of dehydration for other reasons, such as high-output stomas or those with vomiting and diarrhoea. There is a clear link between dehydration and patient safety with the increased prevalence of situations such as pressure sores, falls, sepsis, urosepsis and kidney injury. However, the exact scale of dehydration issues in the UK is still unknown.21
Assessment is a vital aspect of the work of the nurse. It is therefore irrelevant in which context the care is taking place, since nurses must assess, plan and implement care to promote health, aid recovery and prevent deterioration. In the community setting, timely assessment and appropriate care may help prevent hospital admission and more invasive procedures.22 Therefore assessment of patients’ hydrational state must be a key priority to healthcare professionals and care must be tailored to the individual. This involves consideration of the patient’s medical history, presenting symptoms and current medications.
It has been acknowledged that dehydration can be difficult to diagnose and that no single clinical sign is reliably sensitive. Typically, blood tests are not carried out as frequently in the community as in the hospital setting, but blood testing remains the gold standard diagnostic method for dehydration. This means it is crucial to recognise other signs and symptoms of dehydration.23
As part of the assessment process, observation can reveal some typical signs of dehydration such as dry skin and turgor, dry mouth and thirst.24 Other signs and symptoms might also include dry sunken eyes, headache, tiredness, constipation, dizziness, disorientation, confusion and hypotension. Every healthcare professional must ensure they consider these as possible dehydration symptoms. National Institute for Health and Care Excellence (NICE) guidelines25 focusing on acute kidney injury advise that patients should be monitored to determine initial signs of dehydration. This includes observing for reduced urine output and blood and protein in the urine. Again, these tests are more likely to be carried out on patients in hospital settings, where fluid balance charts are employed, and nurses routinely test and re-test urine on and after admission. Awareness of community nurses in accurately determining risk factors, in conjunction with the patient and their carers, may be crucial in the quest to assess and prevent dehydration.
There are many issues associated with dehydration. Patient care can be affected by omission of adequate assessment and failure to implement preventive measures or treatment. Community nurses must be acutely aware of the need to assess, promote and treat issues of poor hydration to help prevent the problems that can occur. Promoting and maintaining good hydration is therefore one of the most fundamental elements of care and all nurses must remember this in any healthcare setting. Nevertheless, these are tasks not only for the individual community nurse practitioner, but also for managers and all other stakeholders in policy planning quality person-centred care in the community.
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2. Food Standards Agency. Nutritional Guidelines for food Served in Public Institutions Final Report, 2006.
3. Institute of Medicine. Dietary Reference Intakes: Water, Potassium, Sodium, Chloride, and Sulphate Report, 2004:618.
4. Royal College of Nursing and National Patient Safety Agency. Water for Health: Hydration best practice toolkit for hospitals and healthcare, 2007.
5. Lecko C, Best C. Hydration, the missing part of nutritional care. Nursing Times 2013;109(26):12-14.
6. Department of Health. Care in local communities: A new vision and model for district nursing. Stationary Office, 2013.
7. Scottish Government. A Route Map to the 2020 Vision for Health and Social Care. Scottish Government, 2011.
8. Burns J. Patient safety and hydration in the care of older people. Nursing Older People 2016;28(4):21-4.
9. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry Executive Summary, 2013.
10. NMC. The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. NMC, 2015.
11. NHS England. Guidance – Commissioning Excellent Nutrition and Hydration 2015-2018. england.nhs.uk/wp-content/uploads/2015/10/nut-hyd-guid.pdf (accessed 12 July 2016).
12. Dougherty L, Lister S, West-Oram A. (eds.)The Royal Marsden Manual of Clinical Nursing Procedures, 9th edn. The Royal Marsden NHS Foundation Trust, 2015.
13. Cowen M, Ugboma D. Maintaining Fluid, Electrolyte and Acid-Base Balance. In Alexander’s Nursing Practice, 4th edn. Churchill Livingstone, 2011.
14. Benelam B. Recognizing the signs of dehydration. Practice Nursing 2012;21(5):230-235.
15. Williams K, Weatherhead I. Improving nutrition and care for people with dementia. Nutrition 2013;Supp:S20-S25.
16. Braddock D. Aging and developmental disabilities: demographic and policy issues affecting American families. Mental Retardation 1999;37:155-161.
17. National Patient Safety Agency. Understanding the patient safety issues for people with learning difficulties. NPSA, 2004.
18. NHS England. Improving the physical health of people with serious mental illness: a practical toolkit, 2016.
19. Benelam B, Wyness L. Hydration and health: a review. Nutrition Bulletin 2010;35:3-25.
20. Rudolf M, Levene M. Paediatrics and Child Health, 2nd edition. Blackwell Publishing, 2006.
21. Lecko C. Patient safety and nutrition and hydration in the elderly. The Health Foundation, 2013.
22. Webber J. Nurses Handbook of Health Assessment. Lippincott Williams and Wilkins, 2009.
23. National Confidential Enquiry into Patient Outcome and Death. ‘Adding Insult to Injury: A review of the care of patients who died in hospital with a primary diagnosis of acute kidney injury (acute renal failure), 2009.
24. Lewis R. Addressing dehydration. Nursing Standard, 2014.
25. NICE. Acute kidney injury: prevention, detection and management. NICE CG169, 2013.
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